Commissioners and clinicians can improve the value extracted from the respiratory programme budget by rebalancing investment in stop smoking services and pulmonary rehabilitation programmes, and reducing overuse of some inhaled medicines.

The study by IMPRESS analysed which interventions offer most value for a population with chronic obstructive pulmonary disease (COPD).

It applied an analysis developed by Dr Alec Morton and Mara Airoldi| from the Department of Management at the London School of Economics and Political Science supported by the Health Foundation to assess the benefit of different types of intervention. In 2010/11 the NHS in England spent more than £4 billion a year on respiratory illness, £720 million of it on COPD, so what are the best interventions to provide for that investment if we want to reduce mortality from COPD and reduce the burden of breathlessness and other associated problems?

A key finding was that clinical interventions to help those people with COPD who smoke to stop (about 35%) improve their outcomes at a relatively low cost and therefore, given the number of people who smoke, offer value not just to the individuals but also to the population. This is true both for those diagnosed with COPD who smoke and those with COPD who smoke but are as yet undiagnosed (estimated to be as many as 6000 in a population of 300,000). Yet stop smoking services are not routinely offered in hospitals or in other places where there are likely to be substantial numbers of people who smoke.

The study Relative Value also found that there is “substantial overtreatment” of inhaled medicines for patients with mild to moderate disease and that in some cases this could create health problems. In particular, it warns of the risks of prescribing “triple therapy” - multiple inhaled treatments - both because of the risk of causing harm and because of unnecessarily high costs.

It also found that programmes of pulmonary rehabilitation - combining exercise, education and self-management - were particularly cost-effective ways of improving patient outcomes but are under-supplied in many parts of the country.

IMPRESS was set up as a partnership between the British Thoracic Society and the Primary Care Respiratory Society-UK to stimulate improvement and integration of respiratory services. It involves doctors, nurses, allied health professionals, managers and lay people with experience in general practice, community and hospital care.

Steve Holmes, GP, joint author and co-chair of IMPRESS said: “Large amounts of public money are spent in respiratory care but it’s not always used wisely. Healthcare professionals have an ethical responsibility to avoid waste, which means doing what’s best for a patient’s health and avoiding treatments which don’t improve things or which actually make them worse. This report applies health economics to our decision-making to produce the evidence for what provides value and what does not. It’s the most comprehensive study conducted of the value of differing treatments for COPD patients and it may contain some surprises for clinicians"

Mike Ward, joint author of the report, Co-chair of IMPRESS and hospital physician in the Midlands, added “For example we’ve tended to see stop smoking interventions as not our business - as something carried out by public health programmes. We should be arguing for greater investment in specialist stop smoking services for our patients and also for education programmes for us all to have the skills to help people quit.“

The study modelled a population of 300,000 including about 12,000 at risk of COPD of varying degrees of severity. A technique called decision conferencing was then used to assess the effectiveness of different types of treatment and the number of people who could benefit. This enabled the researchers to compare the value of different treatment scenarios in terms of both cost and their use to patients.

The full report, IMPRESS Guide to the relative value of COPD interventions: a population-based approach to improving outcomes for people with chronic obstructive pulmonary disease based on the cost of delivering those outcomes, is available on the IMPRESS website|.

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